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Australian Indigenous HealthBulletin
 

Mortality

Mortality

Major impediments to producing a complete picture of Aboriginal and Torres Strait Islander mortality in Australia are the incomplete identification of Indigenous status in death records and the experimental nature of the recently adopted population estimates [1]. As a result of the incomplete identification of Indigenous status in death records, the 2,914 Aboriginal and Torres Strait Islander deaths registered in 2014 are an underestimate of the actual number of deaths. Also, delays in registration of deaths are more common for Aboriginal and Torres Strait Islander people. For example, of all the Aboriginal and Torres Strait Islander deaths which occurred in Australia in 2011, about 87% were registered in 2011 compared with 95% of non-Indigenous deaths [2].

Based on a linkage study of Indigenous identification in deaths registration and the 2011 Census, the ABS revised its estimates of life expectancy of Indigenous people (see ‘Life expectancy’) [2]. The levels of under-identification, which differed by age-group, jurisdiction and remoteness of residence, were taken into account for the new estimates of Indigenous life expectancy. The ABS noted that correction of the under-estimates of death numbers and rates would need similar adjustments. These findings confirm the caution that the ABS notes should be exercised in the interpretation of the estimates of Indigenous mortality, particularly estimates of trends over time [1]. This caution is reflected in recent ABS publications that do not include detailed tables of Indigenous deaths, nor information about overall death rates. As a result, there is no consistency about the extent of information available for recent years. Reflecting this, readers should be aware that the following sections vary in terms of the years to which they relate.

Box 3: Adjusting for age-structures of populations

Comparison of Aboriginal and Torres Strait Islander and non-Indigenous mortality needs to take account of differences in the age structures of the Indigenous and non-Indigenous populations using a process known as standardisation. (The process is also referred to as age-adjustment.)

Direct standardisation, the preferred method, applies detailed information about Indigenous deaths, including sex and age, to a ‘standard’ population [3]. (In Australia, the 2001 Australian estimated resident population (ERP) is generally used as the standard population.) Direct standardisation enables accurate comparisons of Indigenous and non-Indigenous rates, and time-series analyses.

If detailed information is not available, it is still possible to use indirect standardisation to estimate standardised mortality ratios (SMRs). The SMR is the ratio of the numbers of deaths (or of other health measures) registered/observed to the number expected. SMRs allow for the comparison of numbers of registered Indigenous deaths with the numbers expected from the corresponding age-sex-specific death rates for the total population or, preferably, the non-Indigenous population.

Age-standardised death rates

There were 2,914 deaths in Australia in 2014 where the deceased person was identified as Aboriginal and/or Torres Strait Islander [1]. The age-standardised death rate of 9.6 per 1,000 population for Aboriginal and Torres Strait Islander people was 1.8 times the rate for their non-Indigenous counterparts.

More detailed information about death rates is available for the five-year period 2009-2013 for people living in NSW, Qld, WA, SA and the NT [4]. After age-adjustment, the death rate for Aboriginal and Torres Strait Islander people living in those jurisdictions was 1.7 times the rate for non-Indigenous people (Table 5). The rates for Indigenous people were highest in the NT (1,461 per 100,000) and WA (1,323 per 100,000).

Table 5. Age-standardised death rates, by Indigenous status, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2009-2013

Jurisdiction

Indigenous rate

Non-Indigenous rate

Rate ratio

NSW

804

585

1.4

Qld

964

590

1.6

WA

1,323

552

2.2

SA

818

611

1.3

NT

1,461

612

2.4

Total NSW, Qld, WA, SA & NT

985

585

1.7

Notes:

  1. Rates per 100,000 are directly age-standardised using the 2001 Australia ERP
  2. Rate ratio is the Indigenous rate divided by the non-Indigenous rate
  3. Due to the incomplete identification of Indigenous status, these figures probably under-estimate the true difference between Indigenous and non-Indigenous rates

Source: AIHW, 2015 [4]

Between 1998 and 2013, there was a 16% reduction in the age-standardised death rates for Aboriginal and Torres Strait Islander people in NSW, Qld, WA, SA and the NT; there was also a significant closing of the gap in death rates between Aboriginal and Torres Strait Islander and non-Indigenous people during this time period [4].

Expectation of life

In 2013, the ABS published revised estimates for expectation of life at birth for Indigenous people [2]. After adjustment for the underestimate of the number of deaths identified as Indigenous, the ABS estimated that Aboriginal and Torres Strait Islander males born in Australia in 2010-2012 could expect to live to 69.1 years, 10.6 years less than the 79.7 years expected for non-Indigenous males. The expectation of life at birth of 73.7 years for Aboriginal and Torres Strait Islander females born in Australia in 2010-2012 was 9.5 years less than the expectation of 83.1 years for non-Indigenous females.

Revised estimates were also published for Indigenous people living in NSW, Qld, WA and the NT (Table 6).

Table 6. Expectation of life at birth in years, by Indigenous status and sex, selected jurisdictions, Australia, 2010-2012

Jurisdiction

 

Indigenous status/sex

Indigenous

Non-Indigenous

Difference

Males

NSW

70.5

79.8

9.3

Qld

68.7

79.4

10.8

WA

65.0

80.1

15.1

NT

63.4

77.8

14.4

Australia (unadjusted)

67.4

79.8

12.4

Australia (headline)

69.1

79.7

10.6

Females

NSW

74.6

83.1

8.5

Qld

74.4

83.0

8.6

WA

70.2

83.7

13.5

NT

68.7

83.1

14.4

Australia (unadjusted)

72.3

83.2

10.9

Australia (headline)

73.7

83.1

9.5

Notes:

  1. This table includes two estimates for Australia, The ‘headline’ estimate includes adjustments based on Australia-wide census-related information. These estimates should be used in all situations except those requiring comparisons with the estimates for the states and territories, for which Australia-wide census-related information could not be applied. The unadjusted Australian estimate should be used in situations requiring such a comparison.
  2. Australian estimates are based on deaths in all states and territories
  3. Differences are based on unrounded estimates

Source: ABS, 2013 [2]

Age at death

The median age at death 1 in 2014 for Aboriginal and Torres Strait Islander males ranged from 49.9 years for those living in WA to 57.7 years for those living in NSW (Table 7) [1]. These levels were around 20 years less than those for non-Indigenous males, which ranged from 68.3 years (NT) to 80.3 years (SA).

The median age at death for Aboriginal and Torres Strait Islander females in 2014 ranged from 57.5 years for those living in the NT to 64.1 years for those living in NSW (Table 7) [1]. These levels were also around 20 years less than those for non-Indigenous females, which ranged between 71.3 years (NT) and 85.8 years (SA).

Table 7. Median age at death, by Indigenous status and sex, NSW, Qld, WA, SA and the NT, 2014

JurisdictionIndigenousNon-Indigenous

Male

Female

Male

Female

NSW

57.7

64.1

79.0

85.3

Qld

57.4

62.8

77.7

84.4

WA

49.9

60.0

77.9

84.5

SA

56.5

60.5

80.3

85.8

NT

53.4

57.5

68.3

71.3

All jurisdictions

55.4

61.5

78.6

85.0

Notes:

  1. Information is not available for the other jurisdictions because of the relatively small numbers of deaths
  2. Median age of death is the age below which 50% of deaths occur

Source: ABS, 2015 [1]

In 2010-2014, age-specific death rates were higher for Aboriginal and Torres Strait Islander people than for non-Indigenous people across all age-groups, but the rate ratios were highest in the young and middle adult years (Table 8) [1]. (The rate ratios, based on the numbers of deaths registered, vary according to the levels of Indigenous identification (see above).)

Table 8. Age-specific death rates by Indigenous status and sex, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2010-2014

Age-group (years)

Indigenous

Non-Indigenous

Rate ratio

Males

Females

Males

Females

Males

Females

NSW

0

4.6

4.1

3.9

3.1

1.2

1.3

1–4

27

24

16

14

1.7

1.7

5–14

7.0

9.1

9.0

8.0

0.8

1.1

15–24

71

35

45

21

1.6

1.7

25–34

160

86

67

30

2.4

2.9

35–44

345

195

119

66

2.9

3.0

45–54

682

355

274

164

2.5

2.2

55–64

1,179

926

647

382

1.8

2.4

65+

3,633

3,735

3,952

3,601

0.9

1.0

Qld

0

7.5

6.3

4.5

4.1

1.7

1.5

1–4

35

33

20

15

1.8

2.1

5–14

20

11

11

8.1

1.8

1.4

15–24

105

56

53

25

2.0

2.2

25–34

215

112

79

36

2.7

3.1

35–44

422

248

129

70

3.3

3.5

45–54

879

486

264

165

3.3

2.9

55–64

1,621

1,215

631

370

2.6

3.3

65+

5,137

4,011

3,745

3,353

1.4

1.2

WA

0

7.8

4.5

2.5

2.3

3.1

2.0

1–4

62

44

19

15

3.3

3.0

5–14

35

31

9.1

9.2

3.9

3.4

15–24

209

100

52

24

4.0

4.1

25–34

294

174

79

29

3.7

6.1

35–44

694

398

121

64

5.7

6.2

45–54

1,247

759

234

149

5.3

5.1

55–64

2,194

1,532

557

332

3.9

4.6

65+

5,629

4,577

3,594

3,184

1.6

1.4

SA

0

7.1

6.1

3.2

2.5

2.2

2.5

1–4

11

33

18

18

0.6

1.9

5–14

27

9.5

7.8

8.8

3.5

1.1

15–24

100

69

46

18

2.2

3.8

25–34

215

169

75

36

2.9

4.7

35–44

597

449

148

85

4.0

5.3

45–54

1,123

591

307

178

3.7

3.3

55–64

1,529

1,229

662

390

2.3

3.2

65+

3,724

2,917

4,097

3,830

0.9

0.8

NT

0

14.0

11.9

3.0

4.1

4.7

2.9

1–4

59

101

34

4.6

1.7

22.1

5–14

46

55

16

13

2.8

4.2

15–24

264

150

85

36

3.1

4.2

25–34

406

236

85

27

4.8

8.6

35–44

858

603

113

51

7.6

11.9

45–54

1,589

1,340

317

138

5.0

9.7

55–64

2,751

2,082

683

324

4.0

6.4

65+

6,162

5,918

3,119

2,362

2.0

2.5

All jurisdictions

0

7.1

5.8

3.8

3.2

1.9

1.8

1–4

39

37

18

15

2.2

2.5

5–14

21

19

9.6

8.3

2.2

2.2

15–24

126

66

49

23

2.6

3.0

25–34

237

135

73

32

3.2

4.2

35–44

508

311

125

69

4.1

4.5

45–54

965

583

269

163

3.6

3.6

55–64

1,652

1,253

631

372

2.6

3.4

65+

4,591

4,113

3,860

3,504

1.2

1.2

Notes:

  1. Rates are per 100,000
  2. Rate ratio is the Indigenous rate divided by the non-Indigenous rate
  3. Information is not available for Vic, Tas and the ACT because of the small number of deaths registered in those jurisdictions

Source: ABS, 2015 [1]

Infant mortality

The infant mortality rate (IMR) is the number of deaths of children aged less than one year in a calendar year per 1,000 live births in the same calendar year. In NSW, Qld, WA, SA and the NT in 2012-2014, the Aboriginal and Torres Strait Islander IMR (6.0 per 1,000) was almost twice as high as the non-Indigenous IMR [1](Table 9). The highest Aboriginal and Torres Strait Islander IMR occurred in the NT (13 per 1,000); the lowest occurred in NSW (4.4 per 1,000).

Table 9. Infant mortality rates, by Indigenous status and sex, and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2012-2014

Jurisdiction

Indigenous

Non-Indigenous

Rate ratio

Males

Females

Males

Females

Males

Females

NSW

4.6

4.2

3.7

3.1

1.2

1.4

Qld

6.7

5.5

4.1

4.1

1.6

1.3

WA

5.8

4.4

2.1

2.1

2.8

2.1

SA

9.0

6.0

3.0

2.4

3.0

2.5

NT

13

12

3.1

4.2

4.1

2.9

All jurisdictions

6.5

5.5

3.5

3.2

1.9

1.7

Notes:

  1. Infant mortality rate is the number of infant deaths per 1,000 live births
  2. Rate ratio is the Indigenous rate divided by the non-Indigenous rate
  3. The Indigenous rates are likely to be under-estimated, due to the incomplete identification of Indigenous status on births and deaths records
  4. Due to the small number of deaths registered in Vic, Tas and the ACT, these jurisdictions have been excluded

Source: ABS, 2015 [1]

In the five-year period 2008-2012, Aboriginal and Torres Strait Islander infants most commonly died from the International Classification of Diseases (ICD) ‘Certain conditions originating in the perinatal period’, including birth trauma, disorders relating to foetal growth, and complications from pregnancy, labour and delivery [4]. Aboriginal and Torres Strait Islander infants died from these conditions at 1.6 times the rate of non-Indigenous infants. The second most common cause of infant death was for ICD ‘Signs, symptoms and ill-defined conditions’, which includes sudden infant death syndrome (SIDS); Aboriginal and Torres Strait Islander infants died at 3.3 times the rate of non-Indigenous infants (and, for SIDS alone, at 2.4 times the rate). The third most common cause of infant death was for ICD ‘Congenital malformations’, for which Indigenous and non-Indigenous infants had similar rates (rate ratio of 1.0).

From 1998 to 2012, the IMR for Aboriginal and Torres Strait Islander people has declined by 64%; there was also a significant closing of the gap in IMRs between Aboriginal and Torres Strait Islander and non-Indigenous infants during this time period (by 83%) [5].

Causes of death

Cardiovascular disease was the leading cause of death of Aboriginal and Torres Strait Islander people in 2013, being responsible for 24% of the deaths of Indigenous people living in NSW, Qld, WA, SA and the NT [6]. The next most common causes of death were: ICD ‘Neoplasms’ (mainly cancers) being responsible for 21% of deaths; followed by ICD ‘External causes’ (injury) (15%); ICD ‘Endocrine, nutritional and metabolic diseases’ (including diabetes) (9.1%); and ICD ‘Diseases of the respiratory system’ (8.2%).

In terms of specific conditions, coronary heart disease (CHD) (also known as ischaemic heart disease) was the leading cause of death of Aboriginal and Torres Strait Islander people living in NSW, Qld, WA, SA and the NT in 2013 at a rate 1.6 times that of their non-Indigenous counterparts (Table 10) [6]. The other leading specific causes of death of Aboriginal and Torres Strait Islander people were diabetes (rate ratio: 6.0), chronic lower respiratory disease (rate ratio: 2.4) and lung cancer (rate ratio: 1.8).

Table 10. Numbers and rates of the leading causes of Aboriginal and Torres Strait Islander deaths and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2013

Cause of death

Number

Rate

Rate ratio

Coronary heart disease

321

127

1.6

Diabetes mellitus

202

90

6.0

Chronic lower respiratory disease

148

65

2.4

Lung cancer

140

56

1.8

Suicide

138

24

2.2

Cirrhosis and other liver diseases

124

31

4.7

Cerebrovascular disease

122

67

1.6

Land transport accidents

72

13

2.4

Diseases of the urinary system

66

35

3.1

Certain conditions originating in the perinatal period

60

5.5

2.3

Notes:

  1. See source for the ICD codes for the causes of death
  2. Rates are deaths per 100,000, standardised to the Australian 2001 ERP
  3. Rate ratio is the Indigenous rate divided by the non-Indigenous rate (not shown)

Source: ABS, 2015 [6]

Similarly, in the five-year period 2008-2012 for people living in NSW, Qld, WA, SA and the NT, ‘circulatory diseases’ was the most common cause of death for Aboriginal and Torres Strait Islander people being responsible for 25% of Indigenous deaths, followed by neoplasms (almost entirely cancer; 20%), and external causes of death (injury; 15%) [4]. For all major causes of death, Indigenous people died at higher rates than non-Indigenous people (Table 11).

Table 11. Proportion and age-standardised death rates of the leading causes of Indigenous deaths and Indigenous:non-Indigenous rate ratios, NSW, Qld, WA, SA and the NT, 2008-2012

Cause of death

Proportion

Rate

Rate ratio

Circulatory diseases

26

286

1.5

Neoplasms

20

224

1.3

External causes

15

75

2.0

Endocrine, metabolic and nutritional disorders (including diabetes)

9.1

103

4.6

Respiratory diseases

7.6

96

1.9

Digestive diseases

5.6

47

2.3

Nervous system diseases

2.5

24

0.9

Kidney diseases

2.5

30

2.6

Infectious and parasitic diseases

2.4

19

2.1

Conditions originating in the perinatal period

2.1

4.3

1.6

Other causes

7.4

76

1.6

All causes

100

986

1.7

Notes:

  1. Due to under-identification of Indigenous deaths, these rates are likely to under-estimate the true differences between the Indigenous and non-Indigenous populations
  2. Rates are per 100,000 population
  3. Rate ratio is the Indigenous rate divided by the non-Indigenous rate

Source: AIHW, 2015 [4]

In 2013, the leading specific causes of death differed for Aboriginal and Torres Strait Islander males and females living in NSW, Qld, WA, SA and the NT [7]. For Aboriginal and Torres Strait Islander males, the two leading specific causes of death were CHD followed by suicide, and chronic lower respiratory disease. For non-Indigenous males, the leading causes of death were CHD, lung and related cancers, and cerebrovascular disease. The leading causes of death for Aboriginal and Torres Strait Islander females were diabetes, CHD, and lung and related cancers. For non-Indigenous females, the leading causes of death were CHD, dementia (including Alzheimer’s disease), and cerebrovascular disease.

Maternal mortality

Box 4: Maternal deaths

Maternal deaths refer to pregnancy-related deaths occurring to women during pregnancy or up to 42 days after delivery [8]. Direct maternal deaths refer to those resulting from obstetric complications (including pregnancy, labour, and first few weeks after delivery) from interventions, omissions, and incorrect treatment. Indirect maternal deaths refer to those resulting from a previously existing disease, or a disease that developed during pregnancy, that were not a direct result of obstetrics but aggravated by pregnancy.

Maternal mortality ratios (MMRs) are calculated by dividing the number of maternal deaths (direct and indirect) by the number of women who gave birth to babies weighing at least 400 grams or that reached at least 20 weeks gestation; this result is then multiplied by 100,000. 

In Australia in 2008-2012, eight of the 102 maternal deaths were of Aboriginal and Torres Strait Islander women (Indigenous status was not reported in 23 of the deaths) [8]. The leading causes of maternal death among Indigenous women were cardiovascular conditions, sepsis, and psychosocial conditions.

Reflecting the higher rate of confinements among Indigenous women, the MMR for Aboriginal and Torres Strait Islander women in 2008-2012 was 13.8 deaths per 100,000 confinements, around 2.1 times higher than the ratio of 6.6 per 100,000 for non-Indigenous women [8][9][10][11][12][13](Table 12). For direct maternal deaths, the ratio of 6.9 per 100,000 for Indigenous women was 2.2 times the ratio of 3.2 per 100,000 for non-Indigenous women.

Table 12. Numbers of women who gave birth and maternal deaths, and maternal mortality ratios, by Indigenous status, Australia, 2008-2012

Indigenous status

Women who gave birth

Maternal deaths

Maternal mortality ratio

Indigenous

57,979

   

Direct and indirect maternal deaths

 

8

13.8

Direct maternal deaths

 

4

6.9

Non-Indigenous

1,428,131

   

Direct and indirect maternal deaths

 

94

6.6

Direct maternal deaths

 

45

3.2

Notes:

  1. Maternal mortality ratio is the number of maternal deaths divided by the number of women who gave birth (in 100,000s)
  2. Due to some uncertainty about the numbers of Indigenous deaths and confinements, some caution must be exercised in the interpretation of the ratios
  3. The non-Indigenous numbers and ratios include deaths for which Indigenous status was not known. This probably results in a slight, unknown over-estimate of non-Indigenous numbers and ratios, and a resultant under-estimate of the differences between Indigenous and non-Indigenous women

Source: Derived from Laws, Li, Sullivan, 2010 [9], Li, McNally, Hilder, Sullivan, 2011 [10], Li, Zeki, Hilder, Sullivan, 2012 [11], Zeki, Hilder, Sullivan, 2013 [12], Hilder, Zhichao, Parker, Jahan, Chambers, 2014 [13], Humphrey, Bonello, Chughtai, Macaldowie, Harris, Chambers, 2015 [8]

Avoidable mortality

Avoidable mortality refers to deaths that could have been prevented with timely and effective health care, including early detection and effective treatment, as well as appropriate modifications of lifestyle behaviours (such as quitting smoking)[14].

There were 7,079 deaths from avoidable causes among Aboriginal and Torres Strait Islander people aged 0-74 years living in NSW, Qld, WA, SA and the NT in the five-year period 2008-2012 [4]. Age-adjusted rates for avoidable deaths of Indigenous people were highest in the NT (789 per 100,000) and lowest in NSW (304 per 100,000) [5]. Aboriginal and Torres Strait Islander people died from avoidable causes at 3.0 times the rate of non-Indigenous people.

In 2008-2012, the most common conditions contributing to avoidable deaths among Aboriginal and Torres Strait Islander people aged 0-74 years living in NSW, Qld, WA, SA and the NT were CHD (19%), cancer (18%), diabetes (10%), and suicide (8.9%) [5]. The death rates from avoidable causes were around twice as high for Indigenous people than for non-Indigenous people for cancer and suicide, four times higher for CHD, and 12 times higher for diabetes.

Between 1998 and 2012, after age-adjustment, there was a 27% decline in the death rate from avoidable causes for Aboriginal and Torres Strait Islander people aged 0-74 years living in NSW, Qld, WA, SA and the NT [5].

References

  1. Australian Bureau of Statistics (2015) Deaths, Australia, 2014. Retrieved 12 November 2015 from http://www.abs.gov.au/ausstats/abs@.nsf/mf/3302.0?OpenDocument
  2. Australian Bureau of Statistics (2013) Life tables for Aboriginal and Torres Strait Islander Australians, 2010-2012. Canberra: Australian Bureau of Statistics
  3. Australian Institute of Health and Welfare (2011) Principles on the use of direct age-standardisation in administrative data collections: for measuring the gap between Indigenous and non-Indigenous Australians. Canberra: Australian Institute of Health and Welfare
  4. Australian Health Ministers' Advisory Council (2015) Aboriginal and Torres Strait Islander health performance framework 2014 report. Canberra: Department of the Prime Minister and Cabinet
  5. Steering Committee for the Review of Government Service Provision (2014) Overcoming Indigenous disadvantage: key indicators 2014. Canberra: Productivity Commission
  6. Australian Bureau of Statistics (2015) Causes of death, Australia, 2013. Canberra: Australian Bureau of Statistics
  7. Australian Bureau of Statistics (2015) Causes of death, Australia, 2013: Deaths of Aboriginal and Torres Strait Islander Australians [data cube]. Retrieved 31 March 2015 from http://www.abs.gov.au/ausstats/subscriber.nsf/log?openagent&3303_12%20%20deaths%20of%20aboriginal%20and%20torres%20strait%20islander%20australians.xls&3303.0&Data%20Cubes&4D9A9ADDB3C2F0ACCA257E18000F913C&0&2013&31.03.2015&Latest
  8. Humphrey MD, Bonello MR, Chughtai A, Macaldowie A, Harris K, Chambers GM (2015) Maternal deaths in Australia 2008-2012. Canberra: Australian Institute of Health and Welfare
  9. Laws PJ, Li Z, Sullivan EA (2010) Australia's mothers and babies 2008. Canberra: Australian Institute of Health and Welfare
  10. Li Z, McNally L, Hilder L, Sullivan EA (2011) Australia's mothers and babies 2009. Canberra: Australian Institute of Health and Welfare
  11. Li Z, Zeki R, Hilder L, Sullivan EA (2012) Australia's mothers and babies 2010. Canberra: Australian Institute of Health and Welfare
  12. Li Z, Zeki R, Hilder L, Sullivan EA (2013) Australia's mothers and babies 2011. Canberra: Australian Institute of Health and Welfare
  13. Hilder L, Zhichao Z, Parker M, Jahan S, Chambers GM (2014) Australia’s mothers and babies 2012. Canberra: Australian Institute of Health and Welfare
  14. Page A, Tobias M, Glover J, Wright C, Hetzel D, Fisher E (2006) Australian and New Zealand atlas of avoidable mortality. Adelaide: Public Health Information Development Unit, University of Adelaide

Endnotes

  1. The median age at death is the age below which 50% of people die. Because the measure partly reflects the age structures of the respective populations, it is a less precise measure than age-specific death rates, which are summarised below.
 

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